Diabetes Management Flashcards
Diabetes management in older adults requires an individualized approach that considers…
Duration of diabetes + presence of complications
Co-morbid health conditions + medications
Functional status, cognition
Availability of supports
Kidney fx decline
Brain more sensitive to hypoglycemia
Altered senses - decreased vision, hearing, peripheral neuropathy
Cognitive impairment and diabetes are interlinked via…
Cognitive decline (via medications, or aging) may lead to reduced ability to perform diabetes management +/- self care tasks. May lead to hypo or hyperglycemia which can further induce cognitive decline.
The ACCORD trial explored blood glucose targets in older adults. This trial found that…
Harms are evident with aggressive BG lowering and were associated with increased mortality - targets and treatments need to be individualized to optimize risk vs. benefit
Intensive lowering of A1C is associated with ____. However…
Decreased rates of nephropathy, neuropathy, retinopathy, and CV events. However, time to benefit is usually 5-10+ years of treatment.
Achieving a “balanced” A1C (7.5-8.5%) is associated with…
Minimal hypoglycemia
Decreased medication AE’s and regimen complexity
A shift in diabetes treatment is…
Using medications that have evidence for improving clinical outcomes
Metformin, GLP-1 RA’s, SGLT2-inhibitors
Insulin + sulfonyl-ureas still most-used antihyperglycemics…
When setting glycemic targets for older patients, we need to consider…
Duration of diabetes
Risk of CV events vs. risk of hypoglycemia
Functional capacity, other cormorbidities
Available resources + supports
A healthy older adult with diabetes is considered…
Functionally independent
Few comorbidities, no cognitive concerns
10+ years of healthy life expectancy
A healthy older adult with diabetes can have these glycemic targets for treatment…
Same BG as someone in younger population
A1C below 7%
Pre-prandial 4-7 mmol/L, post-prandial 5-10 mmol/L
Will likely have a positive benefit
A functionally dependent adult can be classified as someone who has issues with ____. Good glycemic targets for them would be…
IADL’s.
A1C 7.1-8%.
Pre-prandial 5-8 mmol/L, post-prandial <12 mmol/L
Avoid insulin, sulfonylureas !
Higher risk of hypoglycemia, and may not be as likely to benefit in ~10 years
People who are classified as severely frail and/or have dementia usually have looser BG targets; this is usually around…
A1C 7.1-8.5%
Pre-prandial 6-9 mmol/L, post-prandial <14 mmol/L
Glycemic targets for an individual in end-of-life care…
Are irrelevant - provide comfort care and avoid symptomatic hypo/hyperglycemia
Trends in diabetes management in long-term care include…
Overtreatment - high rates of insulin/sulfonylurea use, high rates of hypoglycemia - knowledge gaps in staff regarding diabetes care.
Main goal is to avoid hypoglycemia
Not really any point in “diabetic diets,” quality of life is more important
Hypoglycemia is defined by…
BG < 4 mmol/L
Hypoglycemia can result in severe consequences in older adults such as…
Falls, injuries
Confusion, delirium - repeated episodes increases risk of dementia
Seizures, comas
CV event risk
Overall increased risk of mortality
Risk factors for hypoglycemia include…
More intensive BG control
Previous episodes
Hypoglycemia unawareness - autonomic neuropathy
Cognitive impairment or issues with mobility
Unpredictable eating patterns
Medications that increase risk of hypoglycemia include…
Diabetes medications - Basal-bolus insulin > intermediate acting insulin > long-acting basal insulin - sulfonylureas > repaglinide
Others - beta-blockers, quinolones, alcohol
Autonomic signs + symptoms of hypoglycemia include…
Shaking, palpitations, dry mouth
Anxiety, sweating (night sweats)
Hunger, nausea, paleness
Neuroglycopenic signs + symptoms of hypoglycemia include…
Difficulty concentrating, speaking
Confusion, irritability
Weakness, decreased coordination, falls
Vision changes, headache
Asymptomatic hypoglycemia is associated with…
Population?
Increased age
Longer duration of diabetes
Repeated episodes of hypoglycemia, intensive BG control
Cognitive impairment
Important patient/caregiver education that is key for addressing hypoglycemia risk includes…
Skipping prandial insulin/repaglinide dose if missing a meal - but also importance of eating regularly
Ensure a hypoglycemia management plan is in place
We can help address hypoglycemia risk via reviewing…
Glycemic targets
Adherence to medications - double dosing?
Reeassessment of medications that may contribute to hypoglycemia
Symptomatic trends
Hypoglycemic episodes can be managed via…
Treatment
15-20g carbohydrates
Glucagon for severe episodes (lack of consciousness)
Continuous glucose monitoring is recommended for older adults with…
Type 1 diabetes
Type 2 diabetes on basal-bolus insulin regimens (asymptomatic or recurrent hypoglycemia)
For cardiovascular risk management in diabetes, these medications are recommended…
Statins for all patients 40+
ACEI/ARBs for all patients 55+
Remember to consider co-morbidities, frailty, AE risk vs. benefit (time to benefit)
General considerations to take when evaluating a diabetes medication regimen include…
Medications with low risk of hypoglycemia are preferred - avoid overtreatment
Consider comorbidities (heart failure, CVD, CKD) - cardio/renal benefit from medications?
Re-evaluate treatment goals + regimens as health, functional status, or social supports change
Consider that deprescribing will increase A1C by amount it is lowered.
Lifestyle/non-pharm measures that are always good to consider with diabetes management in older adults include…
Nutritional education
Weight loss (but NOT in frail, older adults)
Exercise - resistance training
Pros of using metformin include…
Effective 1st line agent in reducing A1C and providing CV benefit
Low hypoglycemic risk
Affordable, convenient
Cons of using metformin include…
Renal elimination - risk of accumulation in CKD. Not recommended if GFR < 30 mL/min
GI upset, diarrhea
SADMANs drug
Monitor for vitamin B12 deficiency periodically
Pros of using SGLT2 inhibitors include…
CV + Renal outcome benefits
Low risk of hypoglycemia - less effective for A1C lowering, especially with reduced renal function
Cons of using SGLT2 inhibitors include…
Risk of orthostatic hypotension - volume depletion
Yeast infections, UTI’s, worsening urinary incontinence
$$$
Pros of using GLP-1RA’s include…
CV + Renal benefit
Effective A1C lowering, but still low risk of hypoglycemia
Weight loss if desirable
Once weekly injectable available
Cons of using GLP-1RA’s include…
N/V/D, decreased appetite - may increase frailty
Requires injection
$$$
Pros of using DPP-4 inhibitors include…
Low hypoglycemia risk - moderate effect on A1C
Well-tolerated + convenient, no effect on weight
Cons of using DPP-4 inhibitors include…
No established benefits for CVD, CKD
May need to avoid in heart failure
$$$
Pros of using sulfonylureas include…
Effective A1C lowering (~1%)
Affordable, convenient
Administration of insulin in older adults requires…
Adequate cognitive, visual, and motor skills
Cons of using sulfonylureas include…
Hypoglycemic risk especially with irregular eating habits
Weight gain
No eastablished outcomes - potentially may increase CV risk
This insulin regimen is associated with the lowest-risk of hypoglycemia…
Once daily basal insulin - long acting insulin analogues
This insulin is associated with the highest risk of hypoglycemia…
Multiple daily insulin injections - basal + bolus
May need re-evaluation in older adults with cognitive decline, limited function, or life-limiting illness
When adjusting insulin dosing, we should…
Fix lows first, fix highs later
Adjust by 1-2 units at a time, and 1 insulin at a time
____ BG levels are best for checking lows…
Pre-prandial
____ BG levels are best for assessing adequacy of bolus insulin…
Post-prandial
Frequency of BG monitoring…
Needs to be individualized - overmonitoring is common
Consider stability of treatment regimen + risk of hypoglycemia
Is it actionable by either patient or HCP??
A1C should be monitored…
Every 3-6 months
In older adults, we need to be more aware of ____ with diabetes medications
Circumstance?
Sick-day management
SADMANS
